Nokea
The nurse is teaching an unlicensed assistive personnel about the care of clients with self-mutilation. Which of the following, if stated by the unlicensed personnel about self-mutilation, demonstrates that the teaching has been effective?
- A. It is a means of getting what the person wants.'
- B. It is a nonserious event that can be ignored.'
- C. It is a way to express anger and rage.'
- D. It is a form of manipulation.'
Correct Answer: C
Rationale: Self-mutilation is often a way to express intense emotions like anger or rage, indicating the assistant understands its emotional significance.
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A client with a history of stroke is prescribed clopidogrel (Plavix). The nurse should monitor the client for which of the following adverse effects?
- A. Bleeding.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk, requiring monitoring.
Which of the following actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.
- A. Have the client state his or her name.
- B. Check the name on the arm band with the name on the medication.
- C. Learn to recognize the client.
- D. Check the client's room number.
- E. Compare the date of birth on the client's chart to the date of birth on the client's armband.
Correct Answer: A,B,E
Rationale: Using two identifiers, such as the client's name, armband, and date of birth, ensures accurate medication administration. Room number and visual recognition are not reliable.
Which of the following would be most important for the nurse to include in the teaching plan for a client who is taking phenelzine (Nardil)?
- A. Eating a normal amount of salt in the diet.
- B. Drinking 10 to 12 glasses of water each day.
- C. Allowing 10 days to achieve therapeutic effects.
- D. Avoiding foods high in tyramine.
Correct Answer: D
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods to prevent hypertensive crisis.
When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.
- A. Having suction equipment readily available
- B. Keeping all the lights on in the room at night
- C. Keeping a padded tongue blade at the bedside
- D. Assisting the client to ambulate in the hallway
- E. Monitoring the client closely while showering
- F. Locking the client's bed in its lowest position
Correct Answer: A,D,E,F
Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.
The nurse calls the primary health care provider to express concerns about a chemotherapeutic medication dose prescribed by the primary health care provider being too high. The primary health care provider office informs the nurse that the primary health care provider has left town and will not be available for several days. What action should the nurse take next to assure client safety?
- A. Reschedule the client's chemotherapy until the next week.
- B. Withhold giving the medication until the primary health care provider's partner makes rounds.
- C. Telephone the answering service and confer with the on-call primary health care provider.
- D. Confer with the pharmacist, who agrees the dose is too high, and then reduces the dose accordingly.
Correct Answer: C
Rationale: If the nurse believes a primary health care provider's prescription to be in error, the nurse must clarify the dosage with the client's primary health care provider or the primary health care provider's substitute before administering the medication. Rescheduling the client's chemotherapy is incorrect. Chemotherapy must be administered on a specific schedule for maximum effect with minimum adverse effects. Additionally, only a prescriber can withhold or reschedule chemotherapy. Withholding the medication until the partner makes rounds is incorrect. Chemotherapy agents must be administered in the proper combinations or sequence in order to be effective. Checking with the pharmacist can assist the nurse in determining whether the dose prescribed is incorrect, but the nurse or pharmacist cannot alter the dose without a revised prescription from a licensed primary health care provider with prescriptive authority.